Sexual Victimization, Health Status, and VA Healthcare Utilization

Among Lesbian and Bisexual OEF/OIF Veterans

Kristin M. Mattocks, PhD, MPH1,2, Anne Sadler, PhD, RN3,4, Elizabeth M. Yano, PhD, MSPH5,6,
Erin E. Krebs, MD, MPH7,8, Laurie Zephyrin, MD, MPH, MBA9, Cynthia Brandt, MD, MPH10,11,
Rachel Kimerling, PhD12, Theo Sandfort, PhD13, Melissa E. Dichter, PhD, MSW14,
Jeffrey J. Weiss, PhD, MS15, Jeroan Allison, MD, MS2, and Sally Haskell, MD10,11

1
VA Central Western Massachusetts, Leeds, MA, USA; 2Department of Quantitative Health SciencesUniversity of Massachusetts Medical School,
Worcester, MA, USA; 3Comprehensive Access & Delivery Research and Evaluation (CADRE), Mental Health Service LineIowa City VA Health Care
System, Iowa City, IA, USA; 4Department of PsychiatryUniversity of Iowa Hospitals and Clinics, Iowa City, IA, USA; 5VA Greater Los Angeles HSR&D
Center of Excellence for the Study of Healthcare Provider Behavior, Sepulveda, CA, USA; 6UCLA School of Public Health, Los Angeles, CA, USA;
7
Center for Chronic Disease Outcomes ResearchMinneapolis VA Health Care System, Minneapolis, MN, USA; 8University of Minnesota Medical
School, Minneapolis, MN, USA; 9Department of Veterans Affairs, Washington, DC, USA; 10VA Connecticut Healthcare System, West Haven, CT, USA;
11
Yale University School of Medicine, New Haven, CT, USA; 12National Center for PTSD, Center for Health Care EvaluationVA Palo Alto Health Care
System, Menlo Park, CA, USA; 13HIV Center for Clinical and Behavioral StudiesColumbia University, New York, NY, USA; 14Center for Health Equity
Research and Promotion (CHERP)Philadelphia VA Medical Center, Philadelphia, PA, USA; 15Department of Medicine, Division of General Internal
MedicineMount Sinai School of Medicine, New York, NY, USA.

BACKGROUND: Many lesbian and bisexual (LB) women
veterans may have been targets of victimization in the
military based on their gender and presumed sexual
orientation, and yet little is known regarding the health
or mental health of LB veterans, nor the degree to which
they feel comfortable receiving care in the VA.
OBJECTIVE: The purpose of this study was to examine
the prevalence of mental health and gender-specific
conditions, VA healthcare satisfaction and trauma
exposure among LB veterans receiving VA care com-
pared with heterosexually-identified women veterans
receiving.
DESIGN: Prospective cohort study of Operation Endur-
ing Freedom/Operation Iraqi Freedom (OEF/OIF) wom-
en veterans at two large VA facilities.
PARTICIPANTS: Three hundred and sixty five women
veterans that completed a baseline survey. Thirty-five
veterans (9.6 %) identified as gay or lesbian (4.7 %), or
bisexual (4.9 %).
MAIN MEASURES: Measures included sexual orienta-
tion, military sexual trauma, mental and gender-specif-
ic health diagnoses, and VA healthcare utilization and
satisfaction.
KEY RESULTS: LB OEF/OIF veterans were significant-
ly more likely to have experienced both military and
childhood sexual trauma than heterosexual women
(MST: 31 % vs. 13 %, p<.001; childhood sexual trauma:
60 % vs. 36 %, p=.01), to be hazardous drinkers (32 %
vs. 16 %, p=.03) and rate their current mental health as
worse than before deployment (35 % vs. 16 %, p<.001).
CONCLUSIONS: Many LB veterans have experienced
sexual victimization, both within the military and as
children, and struggle with substance abuse and poor
mental health. Health care providers working with
female Veterans should be aware of high rates of
military sexual trauma and childhood abuse and refer
women to appropriate VA treatment and support groups
for sequelae of these experiences. Future research
S604
should focus on expanding this study to include a
larger and more diverse sample of lesbian, gay, bisexu-
al, and transgender veterans receiving care at VA
facilities across the country.
KEY WORDS: lesbian; health services research; Veterans; women.
J Gen Intern Med 28(Suppl 2):S604–8
DOI: 10.1007/s11606-013-2357-9
© Society of General Internal Medicine 2013
INTRODUCTION
Many lesbian and bisexual (LB) veterans have been
targets of victimization in the military based on their
gender and presumed sexual orientation. Under Don’t
Ask, Don’t Tell (DADT), thousands of LB women were
discharged from military service, while countless others
continued to serve in silence, and, as veterans, sought
care from the Department of Veterans Affairs (VA).1,2
Prior research has shown that many LB veterans
experience discrimination, rejection and/or poor care
following disclosure of their sexuality to healthcare
providers,3 and may engage in strategies to avoid
conversations regarding sexual identity. These experien-
ces may be particularly harmful for LB veterans
returning from military deployments with substantial
physical and mental health problems,4–7 and possibly
compounded by lingering effects of targeted sexual
assault and harassment experienced during military
service based on perceived sexual orientation.8 Recent
research9 indicates that 15.1 % of female OEF/OIF
veterans report experiencing sexual trauma during
JGIM Mattocks et al.: Lesbian and Bisexual Veterans’ Health
military service. Given these healthcare needs among
LB veterans, and the potential for underuse/care avoid-
ance, understanding the healthcare needs of this popu-
lation is crucial if the VA is to provide comprehensive
care to all women veterans, regardless of sexual
orientation.
METHODS
Study Design
The Women Veterans Cohort Study (WVCS) is an ongoing
prospective cohort study involving male and female OEF/
OIF veterans receiving care at two VA facilities in the U.S,
one in the northeast and one in the midwest8.
Sample
Letters describing the study were sent to 3,251 female
OEF/OIF patients enrolled at each facility. Veterans
expressing interest in the study contacted the research
coordinator, read a study description, were consented
and then, if enrolled, were screened for eligibility.
Between July 2008 and October 2011, baseline surveys
were completed by 11 % of female veterans who were
invited to participate (n=365). For this study, data were
obtained from two linked sources: participant surveys
and VA electronic medical records.
Participant Surveys
Our analyses focused on questions that explored sexual
orientation, physical and mental health status, combat and
sexual trauma exposure, and satisfaction with VA care, using
the measures below.
Sexual Orientation. Participants were asked to identify the
sexual orientation category that best described them:
heterosexual, gay or lesbian, bisexual, celibate or asexual, or
not sure. The gay or lesbian and bisexual categories were
combined for these analyses.
Post-Deployment Health Status. Post-deployment health
was measured by asking participants to rate both their current
physical and mental health as: much better than before
deployment, slightly better than before deployment, about the
same, slightly worse than before deployment, or much worse
than before deployment.
Access to Care/Utilization. We asked participants whether
they had private or public insurance and what type of private
(e.g., employer-sponsored) or public (e.g., Medicare,
Medicaid, Tricare) insurance they had. We also asked
S605
whether they had a regular provider, and whether that
provider was a VA provider. Participants with a regular VA
provider were asked if that provider was located in a Primary
Care or Women’s Health clinic.
Combat Trauma. Combat trauma was measured using the
Combat Exposure Scale (CES), a seven-item self-report
measure that has been shown to have a high degree of
validity and reliability.10
Military Sexual Trauma. Sexual trauma during military
service was assessed with the following two questions:
“While you were in the military, did you receive
uninvited and unwanted sexual attention, such as
touching, cornering, pressure for sexual favors, or
sexual remarks?”, and “While you were in the military,
did someone ever use force, or threat of force, to have
sexual contact with you against your will?”. Response
categories included “yes” and “no”.
Childhood Sexual Trauma. Childhood sexual trauma was
assessed with specific questions about the presence and
frequency of sexual abuse at different times in childhood,
including childhood and adolescence prior to the age of 18.11
Response categories included: never, 1–2 times, 3–5 times,
more than 5 times.
Smoking. Smoking status was ascertained by a question
asking respondents about frequency of smoking cigarettes and
data was recoded for respondents who smoked “everyday”
and “some days” as current smokers, and those who smoked
“not at all” as nonsmokers.
Hazardous Drinking. Hazardous drinking (drinking
associated with possible harm) was defined as a score of
eight or more on the Alcohol Use Disorders Identification
Test (AUDIT).12
VA Administrative Data Measures
We used VA administrative records to assess 17 common
women’s health conditions (Appendix Table 5) for which both
LB and heterosexual veterans might seek care. We used the
Agency for Healthcare Research and Quality’s (AHRQ)
Clinical Classifications Software (CCS) framework to map
ICD-9 codes to conditions; specific conditions were grouped
into broad categories.13 A patient was considered to have one
of the designated medical conditions if she had at least one
ICD-9 code for that condition category assigned by a VA
provider during the study period (2008–2011). We used the
same methodology to assess mental health conditions (de-
pression, bipolar disorder, post traumatic stress disorder
[PTSD], and anxiety disorder). We derived a count of primary
and mental health care visits during the study period from
clinic stop codes in VA administrative files.
S606 Mattocks et al.: Lesbian and Bisexual Veterans’ Health JGIM

Analysis Fifty percent of the LB veterans and 35 % of the

We used the χ2 test to compare the demographic, health
care utilization, and clinical characteristics of LB and
heterosexual veterans. Statistical analyses were performed
using SAS version 9.1.3 (SAS, Inc., Cary, North Carolina).
RESULTS
Demographic characteristics of the study sample are presented
in Table 1. Of the 365 OEF/OIF women veterans enrolled in
the study, 35 women (9.6 %) identified as either gay or lesbian
(4.7 %) or bisexual (4.9 %). Thirty women identified as
asexual or celibate, and were excluded from the analysis. LB
and heterosexual veterans did not differ significantly on
demographic characteristics, including age, branch of service,
race/ethnicity, or service component, though LB veterans were
less likely to be married than heterosexual veterans. Most
women veterans had private insurance, but LB women were
significantly less likely to have government-sponsored insur-
ance (e.g., Medicaid) (17 % vs. 32 %, p=.03).
Overall, LB veterans were more likely to have been the
victims of some form of childhood sexual abuse than
heterosexual veterans (60 % vs. 36 %, p<.001). LB
veterans were significantly more likely to have experienced
sexual abuse by an adult prior to their 13th birthday (46 %
vs. 26 %, p=.02) and to have experienced sexual contact
without consent between their 13th–18th birthdays (34 %
vs. 17 %, p=.02) (Table 2).
heterosexual veterans had a diagnosed mental health condition
of PTSD, anxiety disorder, depression, or bipolar disorder (p=
0.10) (Table 3). Since return from deployment, LB veterans
were more likely than heterosexual veterans to rate their
current mental health as worse than before deployment (35 %
vs. 16 %, p<.001), but there were no differences in post-
deployment physical health ratings. LB veterans were more
likely to be current smokers (43 % vs. 23 %, p=.008) and
hazardous drinkers (32 % vs. 16 %, p=.03) than heterosexual
veterans. There were no statistically significant differences in
diagnosed women’s health conditions between the two groups.
Differences in experiences with and perceptions of VA
healthcare are in Table 4. LB veterans were more likely to use
VA providers for their healthcare than heterosexual veterans
(31 % vs. 14 %, p=.01), and were more likely to plan to use the
VA in the future (100 % vs. 88 %, p=.03). There were no
statistically significant differences between the two groups in
perceptions of VA quality, availability of services, or ability to
treat women veterans, although LB rated the latter two criteria
lower than heterosexual veterans.
DISCUSSION
This is one of the first studies to examine health
conditions and healthcare utilization among LB women
veterans in VA care. In our study, LB veterans had

Table 1. Demographic Characteristics of OEF/OIF Women

Veterans (n=335) Table 2. Combat and Military/Childhood Sexual Trauma (n=335)

Characteristic LB Heterosexual p LB Heterosexual p

Veterans Veterans Veterans Veterans
(n=35) (n=300) (n=35) (n=300)
Age (years) Childhood sexual abuse
≤29 55 % 56 % .85 Sexual abuse by adult 46 % 26 % .02
≥30 46 % 44 % prior to 13th birthday
Race Sexual abuse by anybody 31 % 19 % .08
White 83 % 81 % .57 prior to 13th birthday
Black 3 % 8% Sexual contact without 34 % 17 % .02
Hispanic 9 % 4% consent prior to 18th
Other 3 % 2% birthday
Unknown 3 % 4% Any childhood sexual 60 % 36 % .01
Marital Status assault
Married 20 % 35 % .04 Combat Trauma Exposure (CES)
Divorced 6% 13 % Light 49 % 57 % .74
Not Married 74 % 52 % Light to Moderate 26 % 21 %
Branch Moderate 11 % 14 %
Army 66 % 69 % .38 Moderate to Heavy 11 % 7%
Air Force 20 % 17 % Heavy 3% 2%
Marines 9 % 3 % Military sexual trauma
Navy 6 % 10 % Received uninvited 60 % 49 % .20
College education or higher 57 % 46 % .20 sexual attention during
50 K/year or less in personal 71 % 70 % .83 military service
income (touching, pressure,
Private health insurance 55 % 69 % .14 remarks)
Government-sponsored health 17 % 36 % .02 Experienced force or threat 31 % 13 % <.001
insurance (Medicaid, Medicare, for sexual contact during
TRICARE) military service
Service-connected disability 57 % 56 % .89 Forcible sexual contact during 23 % 7% <.001
VA user (at least 1 primary care 86 % 87 % .92 military and prior childhood
or mental health visit in VA) sexual abuse
JGIM Mattocks et al.: Lesbian and Bisexual Veterans’ Health S607

Table 3. Health Conditions Among LB and Heterosexual Veterans female veterans should also be aware of high rates of
(n=335)
combat exposure and childhood abuse and refer women
LB Veterans Heterosexual p to appropriate VA treatment and support groups for
(n=35) Veterans
(n=300) sequelae of these experiences.

Mental health conditions

This study has several limitations. Though only 35
Bipolar disorder 10 % 2% .04 veterans identified as gay, lesbian or bisexual, this self-
Anxiety disorder 27 % 16 % .07 report represents 10 % of our OEF/OIF survey cohort,
Major depression 20 % 11 % .08
PTSD 30 % 25 % .14 which is slightly higher than population estimates of
Any mental health 50 % 35 % .10 lesbians in the military2. Furthermore, because women
condition
Women’s health conditions veterans could enroll in the cohort study between 2008
Menstrual disorders 10 % 14 % .19 and 2011, and Don’t Ask Don’t Tell hadn’t yet been
Female genital 20 % 12 % .11
disorders repealed, there is a possibility that the number of women
Vaginitis 3% 9% .20 identifying as LB in the study is an underestimate of the
Cervical dysplasia/ 13 % 17 % .19
ACSUS true population of women who self-identify as LB. In
Pregnancy 7% 8% .29 addition, we do not have data on the rates of mental health
Benign breast 7% 11 % .46
conditions and substance use disorders of the veterans studied at the
Ovarian cyst 7% 2% .13 time they entered service. Elevated rates of mental health
Benign gynecologic 3 % 4% .38
neoplasms and substance use disorders may have placed them at
Menopausal 10 % 4% .10 increased risk for military sexual trauma. Other limitations
problems of this study include that the original study focused on
Infertility 0% 2 % .66
Sexual dysfunction 0% 1 % .90 broad issues affecting all OEF/OIF women veterans and did
Cervical cancer 0% 1 % .90 not include a comprehensive assessment specific to LB
Osteoporosis 0% 1 % .90
Breast cancer 0% 0 % – veterans as an underserved population, nor any type of
Ovarian cancer 0% 0 % – examination regarding the degree to which LB veterans
Female genital 0% 0 % –
cancer may have felt marginalized or discriminated against in
Uterine cancer 0% 0% – healthcare. Finally, we chose to combine the gay/lesbian
Rates current 17 % 17 % .97
physical category with the bisexual category for these analyses,
health as much which could have led to an overestimation or underestima-
worse
than before tion of associations reported in the analyses.
deployment Very little research on the health and health care needs of LB
Rates current mental 35 % 16 % <.001
health as much veterans has been published to date. Research in non-veteran
worse populations has demonstrated that LB persons often fear
than before
deployment negative consequences of disclosing their sexual orientation
43 % 23 % .01
Current smoker
31 % 16 % .03 Table 4. VA Healthcare Utilization, Satisfaction, and Perceptions
Alcohol disorder of Quality
(AUDIT)
LB Heterosexual p
Veterans Veterans
(n=35) (n=300)
higher rates of mental health problems, smoking, and
poorer self-rated mental health. As echoed in a recent VA healthcare utilization and perception of quality
study,14 a striking finding was that LB veterans had Have only seen VA provider in 31 % 14 % .01
past year (no non-VA or
experienced significantly higher rates of military sexual dual use)
trauma than heterosexual veterans, and had higher rates VA Provider located in a Women’s 24 % 34 % .41
Health Clinic
of hazardous drinking, both consistent with other Plan to use VA in future as either 100 % 88 % .03
studies showing a high correlation between childhood primary or secondary source
of care
sexual abuse and adult substance abuse disorder among Believes the VA provides quality 60 % 57 % .76
lesbian women.15,16 Prior studies have noted high rates healthcare
Believes the VA has needed 51 % 59 % .36
of antigay harassment in the military, ranging from health or mental health services
verbal abuse to physical abuse to death threats, as well Believes VA physicians are 31 % 44 % .16
skilled at treating women
as sexual victimization, particularly among lesbian- Feels welcome at the VA 40 % 32 % .34
identified service members.17 Universal screening for Visits
Average number of primary care 2.96 3.16 .66
military service-related sexual trauma has been imple- visits in past year
mented within VA and has increased rates of mental Average number of mental health 9.18 8.54 .78
visits in past year
health treatment.18 Health care providers working with
S608 Mattocks et al.: Lesbian and Bisexual Veterans’ Health JGIM

and Afghanistan Veterans using Department of Veterans Affairs

to health care providers. These disclosure-related fears may
have been amplified among veterans due to DADT; in our
anecdotal experience, many veterans mistakenly believed
DADT was a policy that VA shared with DOD. With the
repeal of DADT, LB veterans may begin to feel more
comfortable disclosing their sexuality to their VA healthcare
providers without fear of reprisal. In turn, it is essential that VA
healthcare providers create a healthcare environment free of
assumed heterosexuality (e.g. not assuming that all female
veterans require birth control for sexual activity) and ensure
that they are knowledgeable about LB health issues.
Future research should focus on expanding this study to
include a larger and more diverse sample of lesbian, gay,
bisexual, and transgender veterans receiving care at VA
facilities across the country. Questions regarding sexual
orientation and behavior should also be included in all VA
surveys to ensure that the needs of this population are being
met across all areas of VA care.
Acknowledgement:
Contributors: The authors would like to acknowledge Cherry
Sullivan, MPH and Tan Pham, MPH, for their help in preparing the
document.
Funders: This material is based upon work supported by the
Department of Veterans Affairs, Veterans Health Administration, Office
of Research and Development. All authors had full access to all of the
data in the study and take responsibility for the integrity of the data
and the accuracy of the data analysis. The views expressed in this
article are those of the authors and do not necessarily reflect the
position or policy of the Department of Veterans Affairs or the United
Stated Government. Dr. Yano’s time was supported by a VA Health
Services Research & Development (HSR&D) Service Senior Research
Career Scientist Award (RCS #05-195).
Health Care, 2002–2008. Am J Public Health. 2009;99(9):1651–
1658.
7. Mattocks K, Skanderson M, Goulet J, et al. Pregnancy and mental
health among women veterans returning from Iraq and Afghanistan. J
Womens Health. 2010;19(12):2159–2166.
8. Burks D. Lesbian, gay, and bisexual victimization in the military: an
unintended consequence of ‘Don’t Ask, Don’t Tell’? Am Psychol.
2011;66:604–613.
9. Kimerling R, Street A, Pavao J, et al. Military-related sexual trauma
among Veterans Heatlh Administration patients returning from Iraq and
Afghanistan. Am J Public Health. 2010;100(8):1409–1412.
10. Keane T, Fairbank J, Caddell J, Zimering R, Taylor K, Mora C. Clinical
evaluation of a measure to assess combat exposure. Psychol Assess.
1989;1:53–55.
11. Kubany E, Haynes S, Kaplan A, et al. Development and preliminary
validation of a brief broad-spectrum measure of trauma exposure: the
Traumatic Life Events Questionnaire. Psychol Assess. 2000;12(2):210–
224.
12. Babor T, Ramon Dela Fuente J, Saunders J, Grant M. The alcohol use
disorders identification test: Guidelines for use in primary health care.
Geneva: World Health Organization; 1989.
13. Elixhauser A, Steiner C, Palmer L. Clinical Classifications Software (CCS),
2008. Accessed 1/17/2013: http://www.hcup-us.ahrq.gov/toolssoftware/
ccs/ccs.jsp.
14. Booth B, Davis T, Cheney A, Mengeling M, Torner J, Sadler A.
Physical health status of female veterans: contributions of sex partner-
ship and in-military rape. Psychosom Med. 2012;74:916–924.
15. Hughes T, Johnson T, Wilsnack S, Szalacha L. Childhood risk factors
for alcohol abuse and psychological distress among adult lesbians. Child
Abuse Negl. 2007;31:769–789.
16. Hughes T, Wilsnack S, Szalacha L, Johnson T, Bostwick W, Seymour
K, Kinnison K. Age and racial/ethnic differences in drinking and
drinking-related problems in a community sample of lesbians. J Stud
Alcohol. 2006;67:579–590.
17. American Psychological Association Joint Divisional Task Force on
Sexual Orientation and Military Service. Report of the Joint Divisional
Task Force on sexual orientation and military service. Washington, DC:
Accessed 1/17/2013: http://www.apa.org/pi/lgbt/resources/19-44-
taskforce-report.pdf ; 2009.
18. Kimerling R. Evaluation of universal screening for military-related
sexual trauma. Psychiatr Serv. 2008;59:635–640.

Conflict of Interest: The authors declare that they do not have a

conflict of interest. APPENDIX
Corresponding Author: Kristin M. Mattocks, PhD, MPH; VA
Central Western Massachusetts Healthcare System, 421 North
Main Street, Leeds, MA 01053-9764, USA (e-mail: Kristin.mattocks@ Table 5. List of all ICD-9 and V-Codes Used for Gender-Specific
va.gov). Diagnoses

ICD-9 Codes

REFERENCES Uterine cancer 179, 182, 233

Cervical Cancer 180, 233, 795
1. General Accounting Office. Defense force management: DoD’s policy on Cancer of Ovary 183
homosexuality. (Document No. GAO/NSIAD-92-98). Washington, DC; 1992. Cancer, other Female genital organs 181, 183–184, 233
2. Gates G. Lesbian, gay, and bisexual men and women in the US military: Vaginitis, cervicitis, other pelvic 112, 614–616
Updated estimates. The Williams Institute, May 2010. inflammatory conditions
3. Seaver M, Freund K, Wright L, Tjia J, Frayne S. Healthcare prefer- Menstrual disorders 625–626
ences among lesbians: a focus group analysis. J Womens Health. Cervical dysplasia and ASCUS 622, 795
2008;17:215–225. Other female genital disorders 256, 619–626, 629, 795
4. Haskell S, Mattocks K, Goulet J, et al. The burden of illness in the first Female infertility 628
year home: do male and female VA users differ in health conditions and Menopausal disorders 256, 627
healthcare utilization? Womens Health Issues. 2011;21:92–97. Benign gynecologic neoplasms 218–221, 621–624
5. Haskell S, Ning Y, Krebs E, Goulet J, Mattocks K, Kerns R, Brandt C. Ovarian cyst 620
Prevalence of painful musculoskeletal conditions in female and male Pregnancy 630–632, 640–677, 779, 792
veterans in 7 years after return from deployment in Operation Enduring
Breast cancer 174–175, 233
Freedom/Operation Iraqi Freedom. Clin J Pain. 2012;28(2):163–167.
Benign breast conditions 217, 610–611, 793
Sexual dysfunction 302, 607, 625
6. Seal KH, Metzler TJ, Gima KS, Bertenthal D, Maguen S, Marmar CR.
Osteoporosis 733
Trends and risk factors for mental health diagnoses among Iraq
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.